BY: MICHELE LE DOUX SAKURAI
Ms. Sakurai, former director of professional practice, National Association
of Catholic Chaplains, Milwaukee, is currently a chaplain working for Providence
Health System, Portland, OR.
Recent Decades Have Brought a Host of Changes to the Health Care
Chaplain's Role
"I'm no good to anyone!" Andrea's despair was palpable. Her leukemia had
returned and the chemotherapy wasn't working. "I'm stuck in this bed," she said.
"I don't do anything. I can't cook or clean my house; I can't even watch my
grandchildren." She fought back her tears.
The chaplain took her hand. "It has been a long haul, hasn't it?"
Andrea nodded. "Look at my arm," she said. "The lymphodema has made it
useless. I'm useless."
"Useless? Hmmm. Do you remember when first we met?" the chaplain asked.
"It was, what, about three years ago? Remember how your children behaved?"
Andrea rolled her eyes. "Oh, they were awful, weren't they? I was newly
diagnosed and my kids were at each other's throats—all six of them, fighting.
They were impossible—I even had to throw them out of my room twice."
The chaplain smiled. "Yes, I remember. They really had a hard time with
your illness. How are your kids doing now?"
"Oh, really well. They are so attentive and supportive. I can't believe
how they have come together in this. They are my angels."
"That's quite a change, isn't it? To what do you attribute it? Is there
a possibility that it might have to do with how you have handled your illness?"
A broad smile crept over her face as she began to understand. "I guess
I have made a difference, haven't I? My children now know how to . . . Her voice
drifted off as she choked back her tears. "Oh chaplain, God has been good to
me, hasn't he? My children would have never found a way to get along if it had
not been for the last two years. I know that. And now, no matter what happens,
they will be okay. I guess I've made a difference after all."
Chaplains attend to the sacred stories of those confronting change in their
lives. Change can be good: the birth of a long-awaited child or perhaps a surgery
that enhances a patient's quality of life. More often, change is a life-changing
diagnosis or a poor prognosis. As the patient struggles to find some meaning
in it, his or her relationship with God, as well as his or her sense of identity
and self-worth, come into question. Finding meaning is a dynamic process; as
the patient confronts greater challenges, he or she must continually seek ways
to re-ground self within the constructs of a higher power, the illness, and
significant relationships in his or her life. Finding meaning in these life
changes can enhance the patient's quality of life.
In the vignette that began this article, Andrea was grieving significant losses
in her life. The chaplain first affirmed the depth of the loss and then provided
the questions necessary for Andrea to reframe and reflect on her experience.
In the process, Andrea became once again grounded in her sense of worth, in
her relationship with God, and in the larger picture of mystery. In essence,
Andrea was, through her own story and understanding of God, able to find meaning
in this illness at this time.
Training and Certification
The chaplain is trained to listen to the patient's story, to "be present to"
(as we say) the patient's values, and to reframe the crisis in the context of
these values. Being pastorally present requires active, nonjudgmental listening
skills that recognize and name the symbols and metaphors found in the sacred
stories of others. The chaplain uses these stories to elicit avenues of meaning
for the patient or family member. This facilitation can occur only if the chaplain
is aware of his or her own issues…and the way these issues might affect the
ministerial event. This awareness comes through professional training and certification.
In North America, five certifying organizations share common criteria for
certification: the National Association of Catholic Chaplains, the National
Association of Jewish Chaplains, the Association of Professional Chaplains,
the Association for Clinical Pastoral Education, and the Canadian Association
for Pastoral Practice and Education. To be certified as a chaplain by one of
these organizations requires:
- Graduate theological education or its equivalent
- Ecclesiastical endorsement that reflects the approval for ministry by a
faith tradition
- Clinical Pastoral Education (CPE) "equivalent to one year of post graduate
training in an accredited program recognized by the constituent organizations"
1
- Demonstrated clinical competency, which includes adherence to a code of
ethics that protects patients, clients, residents, and their families from
proselytization and potential abuse2
Certification is an assurance to hiring institutions that the chaplain is
both theologically and clinically trained and that the sacred stories and dilemmas
of the patient will be heard and honored.
The Challenge of the Chaplain's Changing Role
The role of the chaplain in health care has changed radically in the past several
decades. There was a time in Catholic health care that the bulk of the spiritual
support was provided by women religious or priests. These people were committed
religious who provided prayer and sacramental support to patients and their
families. However, technological change, reduced numbers of clergy, and the
expanded ministerial opportunities that Vatican II made available to the laity
have contributed to a significant shift in chaplaincy. Chaplains are now expected
to have expertise in areas that reflect the increased sophistication of health
care today. These areas include risk assessment, crisis intervention, advocacy,
cultural and religious diversity, ethics, integration of the patient's story
into a larger faith perspective, ritual support, end-of-life issues, and bereavement
and grief.
Changes in health care in recent years have had a significant impact on how
chaplains function. Before 1997, for example, institutions accredited by the
Joint Commission on Accreditation of Healthcare Organizations (JCAHO) were not
at risk for being cited for deficiencies in pastoral care. The chaplain's accountability
was limited to his or her relationship with the hospital, long-term care center,
or behavioral health facility's administration. As JCAHO has shifted to a more
holistic health care approach, chaplains have become more fully integrated into
the interdisciplinary team. As a member of the team, the chaplain is now responsible
for providing spiritual assessments, interventions, and documentation in the
patient's chart.
In addition, the nation has seen many advances in medicine over the past decade.
New drugs, procedures, technologies—even legislation—have had an impact on the
chaplain's role. Technology has produced tools to enhance and prolong life;
as a result, patients are now given choices that did not exist 10 years ago.
As patients' choices have increased, chaplains have had to prepare for a new
depth of dialogue with them concerning those choices. The ongoing ethical training
of chaplains has become imperative if they are to effectively support a patient's
or a family's journey. Chaplains are continually called to walk the line between
medicine's institutional tendencies and individual conscience. For instance,
Oregon has legalized physician-assisted suicide. Catholic chaplains who are
confronted with requests for assisted suicide must navigate difficult waters.
They must be pastorally present while at the same time honoring Catholic ethics.
The role of the chaplain will continue to grow as new ethical challenges arise
from the medical milieu.
The Chaplain and Community Clergy
Whereas chaplains and clergy seemed interchangeable at one time in the history
of health care, this is no longer the case. The federal government's focus on
a patient's right to privacy has defined the chaplain's role and activities
in contrast to those of community clergy. This is spelled out in the 1996 Health
Insurance Portability and Accountability Act's "Final Rule" regarding privacy
rights.3
A primary function of chaplains is responding to crises: an accident victim
is rushed to the emergency department, for example; or a patient goes suddenly
into cardiac arrest; or another patient dies after a prolonged illness. Because
of shortened lengths of stay in hospitals, chaplains often deal with several
cases in a single visit. In this visit, the chaplain will, first, screen for
spiritual risk (determining whether the patient is in despair and, if so, what
implications that might have for his or her plan of care), and, second, assess
the spiritual resources, the community supports, and patient's own fears and
hopes. The chaplain's interventions may include offering prayer, ritual, and/or
sacraments; reading Scripture; participating in song; processing (e.g., helping
the patients ask questions and address fears) and/or reframing the patient's
journey; or simply listening to what the patient has to say. When appropriate,
the chaplain will provide referrals or reconnect the patient to the faith community
of his or her choice.
The chaplain's role is radically different from that of community clergy.
The more homogeneous environment of the parish reflects common values and beliefs,
and the pastor will articulate questions and answers within that belief system.
The chaplain, on the other hand, must first investigate the patient's faith
journey and values. The questions the chaplain asks and the answers he or she
provides must in each case fit the patient's understanding of a higher power
and the meaning the patient has assigned to his or her life. Chaplains are trained
to honor the patient's agenda; the patient is the person who decides what has
meaning and how that meaning is lived in his or her own spirituality.
Spirituality is the capacity of the human spirit to make meaning, placing
him- or herself within "the unfolding of life in connection with a dimension
beyond self that establishes meaning and values in life."4 Within
the context of spirituality lies religion and "institutional based dogma, rituals,
and traditions."5 Although not everyone subscribes to a religion,
every person is spiritual.
Faith communities and congregations often encourage evangelization, which
can deepen a person's spirituality; in the pluralistic environment of health
care, evangelization is not encouraged because it risks imposing the chaplain's
theology on the patient. Perhaps this is the key distinction between the role
of community clergy and that of chaplains.
In addition, chaplains, as members of the interdisciplinary team and employees
of the health care facility, have access to patients and their medical charts.
Community clergy, on the other hand, are viewed as guests and perhaps partners
in healing, but because they are not on staff, their access to patient information
is limited. The patient's permission is required before staff can place a patient's
name on a clergy list for visitation or notify a pastor of a parishioner's admission.
As a result, the chaplain has increasingly become the voice of advocacy for
the patient. In a crisis, it is often the chaplain who acts as liaison between
the patient (as a member of a faith community) and medical personnel.
For example, a mother who home schooled her three children was admitted into
the hospital for chemotherapy. The side effects of the chemotherapy required
an extended stay. Over time, she became lethargic and her condition began to
deteriorate. Visiting the patient, the chaplain found that the patient's sources
of hope and strength were her farm and her children. However, she would not
permit her children to visit her in a hospital setting. The chaplain discussed
this with the physician, who gave the patient a four-hour pass so she could
go home. On returning to the hospital, the patient became more motivated and
her health quickly improved.
The chaplain serves not only as liaison but also as a resource for patient
and pastor. A medical facility is often like a foreign land to parish priests
or ministers. Navigating the network of personnel and policies, locating parishioners,
identifying patient needs, and following patients at discharge—all this can
be an overwhelming challenge for clergy. In such cases, the chaplain assists
the pastor by acting as a translator of hospital culture. The chaplain can provide
concrete assistance by, for example, helping the visiting pastor to gain access
to wards or providing guidance during an emergency or at a death. The patient's
spiritual journey presupposes collaboration between the chaplain and community
clergy.
The Importance of Spiritual Belief in Healing
The role of faith in healing has received substantial attention in the past
five years. Writers such as Larry Dossey, Harold Koenig, and Kenneth Pargament,
among others, have given us a new understanding of the power of belief to either
heal or harm. As two writers have noted, "a recent meta-analysis of data from
42 published mortality studies involving approximately 126,000 participants
demonstrated that persons who reported frequent religious involvements were
significantly more likely to live longer compared to persons who were involved
infrequently."6
Such research shows how involvement in religious or spiritual activities can
help patients cope with their illnesses. However, just as religious coping and
congregational/parish support can greatly enhance a sick person's quality of
life, they can also bý harmful. "My pastor says if I had enough faith, I wouldn't
be in this mess," bemoaned a terminally ill cancer patient. "If I suffer, then
I can be forgiven and will make it to heaven," said an elderly Roman Catholic
as he refused his pain medication. "I can't talk about my doubts; I am the pastor
and my parishioners would not understand," a dying 40-year-old clergy¢an whispered
tearfully. Other patients speak of their illness as God's punishment or God's
will. Such spiritual distress affects the patient's quality of life.
Perhaps the most important act of healing a chaplain can perform is to empower
the patient or family member to access his or her own spiritual and religious
coping strategies. "Healing," says one writer, "is the humble but also very
demanding task of creating and offering a friendly empty space where strangers
can reflect on their pain and suffering without fear, and find the confidence
that makes them look for new ways right in the center of their confusion."7
This is both the heart and challenge of chaplaincy.
NOTES
- Larry VandeCreek and Laurel Burton, eds., Professional Chaplaincy: Its
Role and Importance in Health Care, Haworth Press, Binghamton, NY, 2001,
p. 7.
- VandeCreek and Burton, p. 16.
- Health Insurance Portability and
Accountability Act's "Final Rule"
- Donna S. Martsolf, "Cultural Aspects of Spirituality in Cancer Care," Seminars
in Oncology Nursing November 1997, pp. 231-236.
- Kenneth I. Pargament, The Psychology of Religion and Coping: Theory,
Research, Practice, Guilford Press, New York City, 1997, p. 38.
- VandeCreek and Burton, p. 11. The study was by Michael McCullough, et al.,
"Religious Involvement and Mortality: A Meta-Analytic Review," Health Psychology,
vol. 19, no. 3, 2000, pp. 211-212.
- Henri J. M. Nouwen, Reaching Out, (Doubleday, Garden City, NJ, 1975,
p. 68.
Copyright © 2003 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.